Provider Demographics
NPI:1609495654
Name:DORSEY, SHANNON DEEANN
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DEEANN
Last Name:DORSEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 LITCHFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-3810
Mailing Address - Country:US
Mailing Address - Phone:937-463-3574
Mailing Address - Fax:
Practice Address - Street 1:1940 LITCHFIELD AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-3810
Practice Address - Country:US
Practice Address - Phone:937-463-3574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRW446595343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)